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Transsexuality and health demands: representations of nursing students

Transexualidad y demandas de salud: representaciones de estudiantes de enfermería

ABSTRACT

Objective:

To analyze the social representations of nursing students about transsexuality and the health demands of transsexual people.

Methods:

Qualitative, descriptive research with undergraduate nursing students from a public university in Rio de Janeiro/Brazil. The data came from a semi-structured interview and lexical analysis using Alceste 2012 software.

Results:

Transsexuality was represented as a transgression, with the transsexual person being objectified as unnatural because they do not identify with their biological sex. Hormone therapy and sex reassignment surgeries were understood as the main demands, being anchored in a pathologizing and medicalizing health sphere. However, the theme is not addressed during graduation, generating unpreparedness for professional life.

Final considerations:

The need to update the academic curriculum, as well as the way of thinking about the care of transsexual people, is essential and urgent for an integral and equitable care.

Keywords:
Transgender persons. Gender identity. Transsexualism. Health. Students; nursing

RESUMEN

Objetivo:

Analizar las representaciones sociales de estudiantes de enfermería sobre la transexualidad y las demandas de salud de las personas transexuales.

Métodos:

Investigación cualitativa, descriptiva con estudiantes de graduación en enfermería de una universidad pública de Río de Janeiro/Brasil. Los datos provinieron de una entrevista semiestructurada y análisis léxico utilizando el software Alceste 2012.

Resultados:

La transexualidad fue representada como una transgresión, siendo objetivada la persona transexual como antinatural porque no se identifica con su sexo biológico. La terapia hormonal y las cirugías de reasignación de sexo fueron entendidas como las principales demandas, ancladas en un ámbito patologizante. ymedicalizando la salud. Sin embargo, el tema no es abordado durante la graduación, generando despreparación para la vida profesional.

Consideraciones finales:

La necesidad de actualizar el currículo académico, así como la forma de pensar la atención a las personas transexuales, es fundamental y urgente para una atención integral y equitativa.

Palabras-clave:
Personas transgénero; Identidad de género; Transexualidad; Salud; Estudiantes de enfermería

RESUMO

Objetivo:

Analisar as representações sociais dos graduandos de enfermagem acerca da transexualidade e as demandas de saúde das pessoas transexuais.

Métodos:

Pesquisa qualitativa, descritiva, com 28 graduandos em enfermagem de uma universidade pública do Rio de Janeiro/Brasil. Realizou-se uma entrevista semiestruturada, no período de novembro de 2017 a março de 2018, e análise tipo lexical com auxílio do software Alceste 2012.

Resultados:

A transexualidade foi representada como uma transgressão, sendo a pessoa transexual objetivada como antinatural por não se identificar com seu sexo biológico. Terapia hormonal e cirurgias de redesignação sexual foram entendidas como as principais demandas, sendo ancoradas numa esfera patologizante e medicalizadora da saúde. A temática não é abordada durante a graduação, gerando despreparo para vida profissional.

Considerações finais:

Faz-se necessário ampliar as discussões sobre gênero na academia, tendo como propósito a transposição do imperativo da heteronormatividade, para que futuros enfermeiros estejam aparelhados para fornecer um cuidado integral e equânime.

Palavras-chave:
Pessoas transgênero; Identidade de gênero; Transexualidade; Saúde; Estudantes de enfermagem

INTRODUCTION

Transsexuality is an object of interest of biomedicine, but it also involves social and cultural aspects, which reveal individual and collective realities, whose behaviors in the face of this phenomenon express values, norms, actions, positions and social relations11. Caravaca-Morera JA, Padilha MI. Social representations of sex and gender among trans people. Rev Bras Enferm. 2017;70(6):1235-43. doi: http://doi.org/10.1590/0034-7167-2016-0581
http://doi.org/10.1590/0034-7167-2016-05...
. Within the scope of Social Sciences, transsexuality has been discussed in the context of relations with the norms and values of the sociocultural universe, in addition to the biological perspective22. Coelho MTAD, Sampaio LLLP. As transexualidades na atualidade: aspectos conceituais e de contexto. In: Transexualidades: um olhar multidisciplinar [Internet]. Coelho MTAD, Sampaio LLLP, organizadoras. Salvador: EDUFBA; 2014 [cited 2019 Mar 10]. p. 13-4.Available from: http://repositorio.ufba.br/ri/handle/ri/16265
http://repositorio.ufba.br/ri/handle/ri/...
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In the biomedical field, the discourse that encompasses transsexuality has exerted a biopower that produces effects beyond the health domain, in the common social discourse, in the understanding that it is a disorder, producing demands for a “cure”22. Coelho MTAD, Sampaio LLLP. As transexualidades na atualidade: aspectos conceituais e de contexto. In: Transexualidades: um olhar multidisciplinar [Internet]. Coelho MTAD, Sampaio LLLP, organizadoras. Salvador: EDUFBA; 2014 [cited 2019 Mar 10]. p. 13-4.Available from: http://repositorio.ufba.br/ri/handle/ri/16265
http://repositorio.ufba.br/ri/handle/ri/...
. Such power relations determine the truth about the sexed body, in which binary sexual differentiation (man and woman) was presented as a previous condition, which was called gender fabrication33. Nascimento LCP. Transfeminismo. São Paulo: Jandaíra; 2021. 192 p.. In this post-structuralist perspective, the boundaries between sex and gender were redrawn, characterizing the idea of binary sex as something natural, an object of interest in power relations that perpetuate sexual and gender hierarchies.

Transsexuality is then a phenomenon that generates concerns and raises debates among different social groups, such as nursing students, particularly in the process of assistance and care for transgender people. Therefore, the understanding of this phenomenon can be anchored in the Theory of Social Representations (SR). The SR seek to capture the meanings and interpretations of the subjects' productions of meanings about a given object that mediate the communication and the relationship of individuals with the world44. Moscovici S. Representações sociais: investigações em psicologia social. Rio de Janeiro: Vozes; 2015..

Concerns related to transsexuality are generated by the social constructions of our society about gender identity, which is visualized as a category of social identity and involves the identification of individuals with genders. The normative of the sex category functions as a regulatory practice that has the power to produce, demarcate and control the bodies and social roles55. Butler J. Problemas de gênero: feminismo e subversão da identidade. 8. ed. Rio de Janeiro: Civilização Brasileira; 2015..

The concept of gender transcends the definition of the term because it is related to subjective individual experiences. It is performative and expressed in the experience itself, and is not determined by culture, nor by biology, but rather by the way individuals perceive themselves and the world around them66. Pardini BA, Oliveira VH. Vivenciando a transexualidade: o impacto da violência psicológica na vida das pessoas transexuais. Psic Sab Prát. 2017 [cited 2019 Mar 10];1(1):110-8. Available from: https://www.unifafibe.com.br/revistasonline/arquivos/psicologiasaberes&praticas/sumario/60/12122017145609.pdf
https://www.unifafibe.com.br/revistasonl...
. Therefore, it also concerns the way in which relations between people - men and women and other identities are conceived, the social constructivism that gives rise to such ideas.

Transsexuality is defined as an experience of an identity character, characterized by conflict with gender norms66. Pardini BA, Oliveira VH. Vivenciando a transexualidade: o impacto da violência psicológica na vida das pessoas transexuais. Psic Sab Prát. 2017 [cited 2019 Mar 10];1(1):110-8. Available from: https://www.unifafibe.com.br/revistasonline/arquivos/psicologiasaberes&praticas/sumario/60/12122017145609.pdf
https://www.unifafibe.com.br/revistasonl...
. In biomedical literature, the concept of transsexuality is sometimes associated with a more permanent and modifying adaptation of the physical body. However, this definition is not well-founded, as it indicates a need to label and standardize ways of being in the world, accessing an individual, private field77. Rocon PC, Sodré F, Zamboni J, Rodrigues A, Roseiro MCFB. O que esperam pessoas trans do Sistema Único de Saúde? Interface. 2018;22(64):43-53. doi: https://doi.org/10.1590/1807-57622016.0712
https://doi.org/10.1590/1807-57622016.07...
. Some people often use the asterisk trans* to refer to different forms of non-cisgender or non-binary experience within transsexuality.

Despite some advances in legislation and guarantees of health rights obtained with the National Policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (LGBTT), in 2008, in Brazil, transsexuality is marked by circumstances of violence, suicides, homicides, mutilation, situations of social conflict that respond to a hygienist hetero-cis-normativity, coercively established in today's society88. Caravaca-Morera JA, Padilha MI. Transnecropolitics: dialogues on devices of power, death and invisibility in the contemporary world. Texto Contexto Enferm. 2018;27(2):e3770017. doi: https://doi.org/10.1590/0104-07072018003770017
https://doi.org/10.1590/0104-07072018003...
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The social and political achievements related to the LGBTQI+ theme (Lesbians, Gays, Bisexuals, Transgenders, Transvestites, Queer, Intersex, Asexuals, other groups and variations) obtained in recent years are undeniable. It is worth mentioning the fact that transsexuality is no longer categorized by the International Classification of Diseases and Related Health Problems in ICD 1099. Porchat P, Ofsiany MC. Quem habita o corpo trans? Rev Estud Fem. 2020;28(1):e57698. doi: https://doi.org/10.1590/1806-9584-2020v28n157698.
https://doi.org/10.1590/1806-9584-2020v2...
. It has been included in ICD 11 in a chapter called “conditions related to sexual health” and is classified as “gender incongruence”. However, regarding the provision of comprehensive and equitable health care,there is still much to be done to meet the demands and needs of this population segment, as the services are still limited to psychiatry and psychology specialties. This can be exemplified by the difficulties faced by these individuals for having access to the transsexualization process in the public health system (SUS) in Brazil1010. Rocon PC, Zamboni J, Sodré F, Rodrigues A, Roseiro MCFB. (Trans) formações corporais: reflexões sobre saúde e beleza. Saúde Soc. 2017;26(2):521-32. doi: http://doi.org/10.1590/s0104-12902017171907
http://doi.org/10.1590/s0104-12902017171...
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Assistance to transgender people should promote their access to health services, guarantee respect for the use of the social identity and full awareness of the indicators of violence and vulnerabilities to which this population is subject. Thus, nurses in training must be prepared to care for transgender people, at all levels of care, understanding the specificities experienced beyond the biological dimension1111. Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS. Nursing care for the transgender population: genders from the perspective of professional practice. Rev Bras Enferm. 2019;72(Suppl 1):299-306. doi: http://doi.org/10.1590/0034-7167-2017-0644
http://doi.org/10.1590/0034-7167-2017-06...
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In this regard, it is important to understand how these future professionals represent transsexuality and the health demands of transsexual people, as knowledge of these representations makes it possible to rethink professional training and, consequently, the provision of care to these people. Social representations are understood as knowledge of common sense and of how individuals interpret reality and construct explanations for social objects. The systems of meanings produced from the interaction and discourses that circulate in social groups aim to define group identity, explain reality, guide practices and justify positions taken77. Rocon PC, Sodré F, Zamboni J, Rodrigues A, Roseiro MCFB. O que esperam pessoas trans do Sistema Único de Saúde? Interface. 2018;22(64):43-53. doi: https://doi.org/10.1590/1807-57622016.0712
https://doi.org/10.1590/1807-57622016.07...
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In view of the above, the present study aims to analyze the social representations of nursing students about transsexuality and the health demands of transgender people.

METHOD

This is an exploratory, descriptive, qualitative study based on the Theory of Social Representations (TSR). The TSR are products of actions and communications originating in the mind, in which collective thinking influences individual thinking and spreads in the social imaginary44. Moscovici S. Representações sociais: investigações em psicologia social. Rio de Janeiro: Vozes; 2015.. The study setting was a federal public university located in the city of Rio de Janeiro, Brazil. The researchers are members of the Sexual and Reproductive Health Research Group, attached to the Human Groups of Universidade Federal do Rio de Janeiro/UFRJ, registered in the Directory of Research Groups of the National Council for Scientific and Technological Development (CNPq). The latter consists of PhD professors, doctoral and undergraduate students.

The participants were 28 nursing students in their final year of university. The following inclusion criteria were adopted: nursing students in the seventh and eighth semesters regardless of gender, with regular enrollment and over 18 years old. The inclusion of these students was considered adequate for the purpose of the study, as these individuals have already gone through different practice scenarios, serving different clients at different levels of health complexities. Students who were on medical leave, whose enrollment was suspended or who were on leave during the data collection period were excluded.

The selection of participants was random, with a personal approach made by a nursing student, under the supervision of the main researcher. All the students who were contacted in person were available and agreed to participate in the study. Interviews were discontinued after data saturation1212. Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Rev Pesq Qual. 2017 [cited 2019 Jun 12];5(7):01-12.Available from: https://editora.sepq.org.br/rpq/article/view/82/59
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Two instruments were used in data collection: a tool for outlining the socioeconomic, demographic and academic profile of the interviewee, and a semi-structured guide designed to extract more in-depth data from the interview, capturing the meanings, content, and practices of the nursing students on transsexuality and the health demands of transgender people.

The interviews were carried out from November 2017 to March 2018. They lasted on average 20 minutes and were conducted in a private place convenient to the participants, recorded and later transcribed in full. The data were analyzed using the ALCESTE software version 2012 (Analyse Lexicale par Contexte d’um Ensemble de Segments de Texte) which integrates a significant amount of statistical tests organized to perform qualitative and quantitative analysis of contextual data1313. Almeida RO, Oliveira FT, Ferreira MA, Silva RC. Newlyundergratuate nurse and intensive care in units of non-critical patients. Rev Bras Enferm. 2019;(Suppl 1):243-51. doi: http://doi.org/10.1590/0034-7167-2017-0713
http://doi.org/10.1590/0034-7167-2017-07...
. The software divides the corpus to be analyzed into Elementary Context Units/ECU which are interview excerpts classified according to their respective vocabularies, characterized by the set of texts to be analyzed.

After text organization, successive divisions of the material were carried out using the Descendant Hierarchical Classification/DHC, which allowed identifying the most evident oppositions between the words of the text and extracting the representative lexical classes1414. Carvalho MCMP, Queiroz ABA, Ferreira MA, Moura MAV, Pinto CB, Vieira BDG. Ineffectiveness of information and acess to heath services; vulnerability to human pappilomavirus. Int Nurs Rev. 2019;66(2):280-9. doi: https://doi.org/10.1111/inr.12500
https://doi.org/10.1111/inr.12500...
. This software groups the semantic roots, defining them by classes, highlighting the function of the word within a given context.

After the development of the corpus, according to the requirements of the ALCESTE computer software, the software was run and had a success rate of 77%, and six lexical classes with two thematic blocks emerged. The thematic block analyzed in this article comprises two classes (5 and 6), one of which concerns the multidimensionality of transsexuality (Class 5) and the other the elaboration of the health demands of this population (Class 6). The analysis and interpretation of data were based on the framework of the Theory of Social Representations.

The study was approved by the Research Ethics Committee of Anna Nery Nursing School/São Francisco de Assis Health Care Institute (CEP-EEAN/HESFA/UFRJ) under Protocol no 2,365,927. To preserve the participants’ anonymity, their names were replaced by a code, i.e. letter P followed by the interview order number (P1, P2, P3… P28).

RESULTS

Most participants were aged 23-27 years (70.8%), were female (95.8%), heterosexual (84%), single (75%), Catholic (33.4%) and Evangelical (29.2%), self-declared black (black and brown) (63%), lived in the northern zone of Rio de Janeiro (50%) and had a monthly family income of 4- 6 minimum wages (58.2%). Regarding care, 60% reported never having assisted a transsexual person. However, among those who had already assisted transsexuals, 90% stated that there were transgender women and that the care was provided in primary care. Asked if the topic was addressed during the undergraduate course, 100% reported that they had not had any classes, work or reading on the subject.

Class 5 - Transsexuality as a transgression: a transsexual person is not natural!

In this class, 40 analyzable words and 34 ECU were identified, representing 16% of the analyzed corpus. The lexical units most associated with Class 3 were: beborn, woman, man, sex, male, organ, female, identify, feel, biological, different, problem, trauma, conflict. Regarding these lexical units and the ECU, it can be seen that this class has contents that are grouped around the meanings about transsexuality as a transgression of what is socially considered normal for the biological sex. This transgression was explained as a result of some problematic or traumatic experience, which consequently generated conflicts and existential problems. Thus, a trans person is objectified as a differentand unnatural individual.

“Transsexuality is a transgression of what is normal for the biological sex of the individual. It's not a natural thing! This happens because that person suffered some form of violence, something that caused trauma”. (P.8)

[...]Transsexuality is not normal, it is not natural. It happens when a trans person does not identify with their biological sex. The person wants to change, to transition to be different. This happens due to traumas experienced that end up generating conflicts and existential disturbances, and the person then wants to change their sex. It’s a different person, it's not natural." (P.16)

Class 6 - Hormone therapy and transsexualization surgery: the medicalizing demand for transgender people's health

Class 6 had 44 analyzable words and 32 ECU, accounting for 15% of the analysis. Considering the ECU and the most associated lexical units (presents, demand, body, health, transition, accept, guidance, hormone, difference, follow-up, assistance, preparation, care) it can be inferred that the contents available in this class concern the understanding of health demands and the specificities of care for transgender people, These demands concerned the biomedical sphere, with interventionist and medicalizing processes related to bodily changes. The specific procedures reported as health demands for these people were hormone therapy and surgical methods such as sex reassignment.

[...] the main health demand of transgender people is related to the hormones they take to modify their bodies. They need physical monitoring, as they often use the hormones indiscriminately and secretly because their families do not accept it [...]”. (P.22)

[...] Health demands are different, special, mainly because of hormones and sex reassignment surgeries. People should be informed of how to take the hormones and know the surgeries and the possible consequences of these methods [...]”. (P.8)

However, to ensure this specific medical care for transgender people, nurses must have prior scientific knowledge about these techniques. The professionals recognize the existence of a gap regarding the approach to transsexuality at the university, as shown in the following ECU:

[...] I did not have access to this content in college. I think that more spaces for events in this area and classes on transsexuality are needed. We would be then able to provide more specific care.” (P 9)

[...] It's just that I don't feel prepared to care for a trans person, because I think it's about much more than providing general care, respecting the other, understanding and listening to them, and ensuring inclusion.I know trans people and I know they have specific hormone treatments and sex reassignment surgeries. So, nurses should learn these techniques, but I did not learn any of that [...]”.(P 21)

Still regarding the biomedical field, another group of respondents think that health care for transgender people should be the same as that provided to any other person, with no need for specialized care, since everyone is equal. Therefore, these professionals feel adequately prepared to serve this segment.

[...] Specific demands? There are none!! Everybody is equal. They are patients like any other.They start taking hormones to change the body's shape, but the care given to them during the surgeries is the same as any other surgical procedure. [...](P. 24)

“The care for these people should be the same as that given to any other person, so I feel prepared to take care of anyone, transsexual or not [...]”. (P.16)

DISCUSSION

Because it is a controversial, emblematic, conflicting and polymorphic object, transsexuality can be analyzed from the psychosocial perspective of the Social Representations (SR). Thus, it was apprehended in the social reality in which it is manifested by nursing students, how it is appropriated, and how this appropriation engenders the behaviors and practices of this group, which are substrates of norms and social relations1515. Apostolidis T, Santos FS, Kalampalikis N. Society against Covid-19: challenges for the socio-genetic point of view of social representations. Pap Soc Represent. 2020 [cited 2021 Fev 10];29(2):3.1-3.14.Available from: http://psr.iscte-iul.pt/index.php/PSR/index
http://psr.iscte-iul.pt/index.php/PSR/in...
-1616. Justo AM, Bousfield ABS, Giacomozzi AI, Camargo BV. Communication, social representations and prevention - information polarization on COVID-19 in Brazil. Pap Soc Represent. 2020 [cited 2021 Fev 10];29(2):4.1-4.18.Available from: https://psr.iscte-iul.pt/index.php/PSR/article/view/533/471
https://psr.iscte-iul.pt/index.php/PSR/a...
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In this context, when they tried to describe and explain transsexuality, the respondents exposed their perceptions and interpretations based on personal, subjective, objective factors and on the totality of knowledge of their social context acquired on the subject, i.e., on common sense. Social, cultural and religious factors influenced the preparation and interpretation of the participants, going from a collective and social construction to an individual and singular representation. It should be noted that this is a group of heterosexual women, from Judeo-Christian religions and with little experience in assisting this population segment.

Given this social context, transsexuality seems to have been anchored in the biological condition from the health-disease perspective, bringing to light the representation of an individual trapped in a body that is not identifiable with their biological sex. The transsexuality issue is reduced to physical and biological aspects, reinforcing the formalization of pathologizing categories, which denotes the compartmentalized view of nursing graduates at the end of the course.

The process of elaboration of social representations involves making classifications and denominations, based on the common sense of the individuals. Positive or negative values are generally attributed to objects, which occupy a certain position in a hierarchy, neutrality is not admitted44. Moscovici S. Representações sociais: investigações em psicologia social. Rio de Janeiro: Vozes; 2015.. This allows us to understand that the participants classify transsexuality as an abnormal behavior of transgression and, in an attempt to give material texture to ideas, they correlate things to words and materialize abstractions in the transsexual person, objectified as unnatural.

The meaning of transsexuality as a transgression is anchored in the social norms expected for each sex (biological) and the possibility that such norms are not observed has a negative value dimension, perceived as disobedience and violation of this social expectation. Thus, the statements made by the nursing students are impregnated with subjectivities associated with gender relations, which contributes to the elaboration of a representation of transsexuality permeated with feelings and that classifies this phenomenon as a stigma.

This representation was also included in a study with nursing students at the State University of Santa Cruz (UESC), in Ilhéus, Bahia, who interpreted transsexuality based on the domain that ranges from biological to pathological aspects, whose technocratic thinking contributed to reaffirm transsexuality as a social transgression. The biological model on the health of transsexuals was based on this logic, and then these individuals were considered to have sexual inversions. Thus, transsexuality came to be defined as a psychiatric disorder that requires medical treatment due to the inadequacy of the subjects to their biological sex1717. Moreira MA, Gomes AJM. Social representations students graduating in nursing about transsexuality. J Nurs UFPE on line. 2013;7(5):4378-88. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/11677/13856
https://periodicos.ufpe.br/revistas/revi...
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The representation is built from socially normative standards, in which the variants are considered abnormal, and where a feeling of abjection and rejection is attributed to any individual who is not within these standards considered as natural and normal for society11. Caravaca-Morera JA, Padilha MI. Social representations of sex and gender among trans people. Rev Bras Enferm. 2017;70(6):1235-43. doi: http://doi.org/10.1590/0034-7167-2016-0581
http://doi.org/10.1590/0034-7167-2016-05...
. It also consists of the pejorative classification of an individual with a particular condition, as is the case of transsexual people, who are often discredited and considered socially incapable1818. Francia-Martínez M, Esteban C, Lespiera Z. Actitudes, conocimiento y distancia social de psicoterapeutas con la comunidad transgénero y transexual. Rev Puertorriqueña Psicol. 2017 [cited 2021 Mar 22];28(1):98-113. Available from: https://psycnet.apa.org/record/2017-15254-006
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This classification reveals an evaluative dimension of the social representations of transsexuality, which contains a heavy load of judgments and assigns negative values to this phenomenon. This dimension is probably marked by ideological and historical factors that correspond to the normative register of cognitions77. Rocon PC, Sodré F, Zamboni J, Rodrigues A, Roseiro MCFB. O que esperam pessoas trans do Sistema Único de Saúde? Interface. 2018;22(64):43-53. doi: https://doi.org/10.1590/1807-57622016.0712
https://doi.org/10.1590/1807-57622016.07...
,1818. Francia-Martínez M, Esteban C, Lespiera Z. Actitudes, conocimiento y distancia social de psicoterapeutas con la comunidad transgénero y transexual. Rev Puertorriqueña Psicol. 2017 [cited 2021 Mar 22];28(1):98-113. Available from: https://psycnet.apa.org/record/2017-15254-006
https://psycnet.apa.org/record/2017-1525...
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The history of how transsexuality was represented over time shows a social memory in the construction of social representation in contemporary times by these academics in the health area, since social memory can be conceived both as a process of strengthening the social representations of the past, built throughout history, and as a process of transformation of these social representations1919. Oliveira JC, Bertoni LM. Memória coletiva e teoria das representações sociais: confluências teórico-conceituais. Gerais Rev Interinst Psicol. 2019;12(2):244-62. doi: http://doi.org/10.36298/gerais2019120205
http://doi.org/10.36298/gerais2019120205...
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One of the references in the theorizing on transsexualism advocated that the inadequacy of gender at birth would be associated with a genetic or endocrine dysfunction. In the 1950s, transsexuality, until then approached as transsexualism, is now considered a pathology, which is supported by the publication of articles and studies in different specialties at that time2020. Dias MB, Zenevich LM. Um histórico da patologização da transexualidade e uma conclusão evidente: a diversidade é saudável. Rev Gênero Direito. 2014 [cited 2021 Mar 22];(2):11-23.Available from: https://vlex.com.br/vid/um-historico-da-patologizacao-546287450
https://vlex.com.br/vid/um-historico-da-...
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In the 1970s and 1980s, transsexualism was considered a gender dysphoria and was incorporated into the psychiatric diagnosis manual in the Diagnostic and Statistical Manual of Mental Disorders (DSM III). Only in 1994, after the publication of DSM IV, the term is replaced by gender identity disorder-GID, confirming the pathologizing character attributed by a normative system of sex and gender that does not contemplate the subjectivity and diversity of forms of construction of gender. Although several classifications have emerged, a new definition was sought that would overcome the disease/treatment condition, which came to be supported by new medical and sociological theories. This culminates in the adoption of the term transsexuality, in which the suffix “ism”, terminology referring to the disease, is replaced by the suffix “ity”, which addresses the way of being, determining a new nomenclature2121. Saadeh A, Cordeiro DM, Caetano LO. Atendimento a transexuais e a travestis: crianças, adolescentes e adultos. In: Ministério da Saúde (BR). Transexualidade e travestilidade na saúde [Internet]. Brasília: Ministério da Saúde; 2015 [cited 2021 Mar 22]. p. 99-110.Available from: https://bvsms.saude.gov.br/bvs/publicacoes/transexualidade_travestilidade_saude.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
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This discussion also proposes the creation of a space for reflecting on the controversy between the natural and the cultural aspects, which has been addressed in the transsexualization process. Nature is responsible for the differences between human groups, such as ethnical traces, religious values, characteristics of social classes, sex and gender. There is a tendency to consider everything that is universal as pertaining to the domain of nature. In general, everything that is regulated by norms, institutions and habits, is particular and belongs to the domain of culture. Thus, no social phenomenon can be considered natural. In turn, the definition of nature, based on biology, is something fixed, universal and immutable. Also, natural life was historically considered sacred2222. Gomes R, Murta D, Facchini R, Meneghel SN. Gênero, direitos sexuais e suas implicações na saúde. Cien Saude Colet. 2018 [cited 2020 Jan 19];23(6):1997-2006.Available from: https://www.scielo.br/pdf/csc/v23n6/en_1413-8123-csc-23-06-1997.pdf
https://www.scielo.br/pdf/csc/v23n6/en_1...
.

The bonds founded on the natural domain are more valuable compared to the context of culture and/or society. Nature is characterized by essential qualities of invariability and immutability. It is something deeper and permanent that cannot be easily broken or changed2222. Gomes R, Murta D, Facchini R, Meneghel SN. Gênero, direitos sexuais e suas implicações na saúde. Cien Saude Colet. 2018 [cited 2020 Jan 19];23(6):1997-2006.Available from: https://www.scielo.br/pdf/csc/v23n6/en_1413-8123-csc-23-06-1997.pdf
https://www.scielo.br/pdf/csc/v23n6/en_1...
-2323. Simpson K. Transexualidade e travestilidade na Saúde. In: Ministério da Saúde (BR). Transexualidade e travestilidade na saúde [Internet]. Brasília: Ministério da Saúde ; 2015 [cited 2021 Mar 22]. p. 9-16.Available from: http://bvsms.saude.gov.br/bvs/publicacoes/transexualidade_travestilidade_saude.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
. These considerations may explain the fact that the nursing students perceived transsexuality as something antinatural and abnormal, based on the intrinsic connotation of sex/gender as something natural.

Transsexuality objectified as transgression was perceived as a consequence of problematic and traumatizing issues, which confer to this experience a psychopathological character2323. Simpson K. Transexualidade e travestilidade na Saúde. In: Ministério da Saúde (BR). Transexualidade e travestilidade na saúde [Internet]. Brasília: Ministério da Saúde ; 2015 [cited 2021 Mar 22]. p. 9-16.Available from: http://bvsms.saude.gov.br/bvs/publicacoes/transexualidade_travestilidade_saude.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
. This led some respondents to explain that non-identification with the biological sex is associated with a traumatic situation experienced by these individuals. Since these difficult situations generate constant conflicts and disturbances about their gender identity, the individuals wish to experience a process of change and transformation.

The bodies and their different possibilities of transformation cannot be dissociated from health and disease processes in transsexuality. Thus, the body can be perceived as a plane where appearance is the imagery dimension of a subject, and on this subject a semiotic body is drawn, not made of flesh and organs, but constituted by a group of signs that order social relations, through connections and transmission between other bodies2424. Popadiuk GS, Oliveira DC, Signorelli MC. The national policy for comprehensive health of Lesbians, Gays, Bisexuals and Transgender (LGBT) and access to the sex reassignment process in the Brazilian Unified Health System (SUS): progress and challenges. Cien Saude Colet. 2017;22(5):1509-20. doi: http://doi.org/10.1590/1413-81232017225.32782016
http://doi.org/10.1590/1413-81232017225....
. Then, the prescriptive representation of compulsory behaviors and practices that are considered right, tolerable and acceptable for male and female bodies is established.

In fact, representations have a conventional and prescriptive nature that models objects, persons or events, according to the language, time and culture of each group. Therefore, it is through conventions, traditions and some social models that the subjects see reality and sometimes they are not aware of these prescriptive impositions of representation44. Moscovici S. Representações sociais: investigações em psicologia social. Rio de Janeiro: Vozes; 2015..

Although the actions carried out by health services are focused on medicalization and the curative process, they are not restricted to the transsexual population. However, the medicalizing process of transsexuality emerged almost entirely for the students interviewed. The health demands of this population group were anchored in the medicalizing process of transsexualization understood as a set of hormonotherapeutic and surgical techniques that facilitate the transformation of the body into the desired gender. The centralization of regulating and prescriptive care arising from discrimination and unpreparedness to meet the specific demands of this population seems to jeopardize the delivery of holistic care and the autonomy of the referred population 2525. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. doi: https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017...
.

Although transsexuality is not a recent condition in the history of mankind, the possibility of reassignment or neophalloplasty appears as a novelty that seems to meet the demands of adaptation of the bodies of transsexual people. Given the refusal of transsexual people to accept the supposed natural and biological destinations possible transformations through technologies, surgeries and medicalization arise.

In this context, a body has diagnostic rites, procedures and prognoses, explained by the clinical anatomical rationality, which organizes, classifies and intervenes, according to norms, through a medicalizing authority2626. Foucault M. Gênese e estrutura da antropologia de Kant. São Paulo: Loyola; 2011.. Through this practice, we attempted to regulate conducts, supported by reified statements of the sciences that place people within pre-established standards. This classification creates universal patterns of the health and disease process, excluding the intersubjective and unique complexity of individuals.

Representations are created by human beings so that they can apprehend the world around them, being socially shared by the group of a social environment to understand, manage or face it2727. Jodelet D. Loucuras e representações sociais. 2. ed. Petrópolis: Vozes; 2015.. According to this line of reasoning, by anchoring transsexuality in the context of biological sciences, students end up interpreting this phenomenon as a biomedical problem caused by a supposed disorder that can be readjusted. Therefore, they exclude the multiple and innumerable possibilities of experiencing transit between genders. Thus, they establish a unique, ideal and universal type of transsexual subject who has only one health demand: the transsexualization process.

The representation of the demand for transsexual people’s health that is constructed, highlights the strong connection between science and common sense, both in the effort to elaborate transsexuality, as well as to resolve the issue of existing mind-body incompatibility. Science, as an epistemological instrument, in the context of transsexuality, was built in an attempt to understand the phenomenon, establishing the cause and effect relationship, as in a process of illness; the hegemonic social common sense interprets this phenomenon of gender and body identity incongruence as perversion2929. Janini JP, Santos RS, Santos LFM, Souza VM. The epistemological construction of transsexuality: the science, nursing and common sense. Esc Anna Nery. 2019;23(3):e20180345. doi: https://doi.org/10.1590/2177-9465-EAN-2018-0345
https://doi.org/10.1590/2177-9465-EAN-20...
.

The association between common sense knowledge and the reified universe builds the representations that are present as systems of interpretation and organization, producing reflections on conduct, choices and social communications11. Caravaca-Morera JA, Padilha MI. Social representations of sex and gender among trans people. Rev Bras Enferm. 2017;70(6):1235-43. doi: http://doi.org/10.1590/0034-7167-2016-0581
http://doi.org/10.1590/0034-7167-2016-05...
. In this regard, the representation of pathologization seems to guide transsexual people’s access to health care, as it reinforces the model of cataloging, healing and standardizing experiences that refer to transsexualities, reducing the subject to a mere patient66. Pardini BA, Oliveira VH. Vivenciando a transexualidade: o impacto da violência psicológica na vida das pessoas transexuais. Psic Sab Prát. 2017 [cited 2019 Mar 10];1(1):110-8. Available from: https://www.unifafibe.com.br/revistasonline/arquivos/psicologiasaberes&praticas/sumario/60/12122017145609.pdf
https://www.unifafibe.com.br/revistasonl...
. Precisely because they admitted this condition, it is possible to understand the reasons that led some nursing students to judge the health demands of transsexual people as not specific, understanding them as being common to any patient, objectifying all people as equal.

These findings were also reported in studies with nurses and nursing students who demonstrated difficulty in understanding the difference between sexual orientation and gender identity, in addition to having little knowledge about the demands and specificities of this population segment. These results point to the need for initiatives in the academic field to expand the range of knowledge and discussions about transsexuality and its health demands, to include cross-cutting theme from a multidisciplinary perspective1717. Moreira MA, Gomes AJM. Social representations students graduating in nursing about transsexuality. J Nurs UFPE on line. 2013;7(5):4378-88. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/11677/13856
https://periodicos.ufpe.br/revistas/revi...
,3030. Oliveira GS, Nogueira JA, Costa JPO, Medeiros RLSFM, Oliveira T, Almeida AS. Health services for lesbians, gays, bisexuals and transvestites / transexuals. J Nurs UFPE online. 2018 [cited 2021 Mar 22];12(10):2598-609.Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/237014/30151
https://periodicos.ufpe.br/revistas/revi...
.

However, this representation that everyone is equal was not unanimous in the study group. Another segment of respondents who coordinated the systems of thoughts and behaviors, understand that vulnerable groups, such as the transsexual population, demand needs that must be adequately addressed by the health systems, although they belong to the biomedical field. This explanation can be a first step so that health professionals in the future know the trajectories of these people, their real health needs and that care practices have direct effects on the lives of such people2525. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. doi: https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017...
. This polarization is an example of the interweaving between representations, identities and social practices, whose group identity processes guide the construction of meanings.

Nevertheless, the reductionist representation of health demands anchored in pathologization is based on common sense about transsexuality, but also on the reified universe of undergraduate nursing curricula. These demands are usually addressed by a biomedical view of care, making the practice of repeating traditional training inevitable, which may neglect the recognition of sexual diversity. The fact that the theme transsexuality and sexual diversity is not addressed during the training of future nurses undermines the logic of comprehensive health and holistic care, as these aspects are not considered as health determinants2525. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. doi: https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017...
.

FINAL CONSIDERATIONS

The present study identified the elements that make up the social representations about transsexuality described by the nursing students, according to the criterion of social relevance, awakening senses and emotions that trigger debates and decision-making related to this phenomenon. The representational field of this object was anchored in the biomedical field, which focused on the understanding of the health demands of this population, demonstrating the cognitive, emotional, imagistic and evaluative dimensions that circulate in this social group about transsexuality.

The findings point to the need for more discussions and reflections on gender issues in the training of nurses with the aim of transposing the imperative of heteronormativity, so that future nurses are equipped to provide comprehensive and equitable care. Dealing with crucial theoretical issues such as the distinction between the restrictive idea of tolerance of diversity and the recognition and respect for differences is fundamental to the understanding of the character of multiculturalism as a political struggle tool, which underpins many discussions on identity issues.

Finally, the limitation of this study lies in the bias of the TRS itself, which understands that other social/group contexts, for example, other universities, other undergraduate courses, in different Brazilian states, can obtain different results, since the representations are systems of meanings that make it possible to interpret events, guide and legitimize human behaviors. Therefore, considering that data were collected from only one public institution of higher education and from only the last two semesters of the nursing course, the present study is limited by its social focus on only one population group.

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Edited by

Associate editor:

Rosana Maffacciolli

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

  • Publication in this collection
    05 June 2023
  • Date of issue
    2023

History

  • Received
    21 Mar 2022
  • Accepted
    07 July 2022
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